Provider Demographics
NPI:1639647399
Name:CARNELL, DUSTIN PAUL (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:PAUL
Last Name:CARNELL
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N MONTGOMERY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-1839
Mailing Address - Country:US
Mailing Address - Phone:814-414-2780
Mailing Address - Fax:
Practice Address - Street 1:427 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-1275
Practice Address - Country:US
Practice Address - Phone:814-652-9114
Practice Address - Fax:814-652-6191
Is Sole Proprietor?:No
Enumeration Date:2018-11-10
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0072892255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer